Jun 22

Electives report

Expedition and Wilderness medicine is typically defined as medical care in a remote setting for days, or even weeks or more. Most of it takes place in the second or third world, open ocean, or at the poles; where an extended time frame care is the norm, as is the need to evacuate patients by carry or, if lucky, pack animal means for at least several days before reaching help. Most of it takes place in remote clinics, bush hospitals, refugee camps, and similar. Besides all of the acute injuries and illnesses, chronic diseases, public health issues, and much more comes into play.

This course has a philosophy of ‘REAL medicine in the REAL world,’ which cannot be more true.

I’ve learnt medicine like I never had in my life, I have finally truly found myself and my role as a medical provider. And I have met so many inspiring individuals throughout the month!

The course started out with 4 days of Jungle Survival Camp where we learnt to survive in the Central American Mayan Jungle with the most minimal amount of necessities while at the same time provide medical care. We also got to learn the uses of many herbal plants for treatment of medical diseases such as malaria. Prior to that camp, my ego told me that I have no problem surviving anywhere in the world: I’ve camped out in the wild African plains for three months, I’ve lived with the locals in South America with only some broken Spanish, I’ve trekked the Malaysian headhunter’s trial and spent a few nights in there, I survived 20 leeches sucking blood out of me, I’ve slept literally under the stars in Mont Blanc at subzero degrees with only a sleeping bag and a baseball jacket yet still managed to wake up alive with O2 saturation only 93% and a body temperature of 37.1 degrees, ten toes still intact . I thought I was made of steel and could survive just about anywhere in the world, I couldn’t be more wrong. 1 day into the jungle survival camp. I started to think otherwise: The Hong Kong insect repellents apparently did not repel the Latino bugs, and throughout the 4 days’ camp I had a total of more than 500 bites from mosquitoes, ticks, and many other unknown Latino bugs. I had quite a disturbing anaphylactic reaction: nausea, headache, not to mention extremely itchy rashes. Took some antihistamine but it was apparently completely insufficient for managing my hypersensitivity. So I had to turn to steroids and singlehandedly injected 10mg dexamethasone right into a vein on my left arm!

After returning to our base from our jungle survival camp, our days are generally packed with lectures focussing on emergency medicine in the remote setting – which all started with Airway, Breathing, and Circulation; and scenarios after scenarios in which we can apply the knowledge we have learnt from the lectures. The scenarios can take place in all sorts of places imaginable – our canteen where someone suddenly started choking; a near-drown spy with hypothermia in a river; a young man who got rolled over by a truck which he was trying to fix; two rangers attacked by a jaguar inside a cave; a lady with an asthmatic attack in the middle of a jungle, and the list goes on. One day we even had to ride a horse to reach a remote cave inaccessible by car! Sometimes the victims or patients in the scenarios are surrogates played by some instructors or students (I have been a victims a few times myself); but many are for real, with real patients and real medical issues. one day we rode horses to get to car-inaccessible areas and did some rescue at a cave. Occasionally some of us get bitten by bugs, have traveller’s diarrhoea or some minor medical conditions. In such cases we will be managing each other and at the same time learning the treatment of some minor but common traveller’s problems.

We also visited some local hospitals and assisted doctors from paediatric consultation at the out-patients clinic to surgical procedures at the operations theatre to suturing cut-wounds from deliberate self-harm with a machete in the accidents and emergency department.

On some weekends we set up a village clinic at a community centre in a village called Armenia. Villagers would be told in advance of our arrival and will all flock in bang on at 8 am on those mornings. Occasionally we received house calls, then 1-2 medical students will follow a doctor to the home of a patient who was either too ill or have a disability which renders him unfit to reach the clinic.

One day we received a house call from a patient with a knee problem. One of our instructors Doctor Keith told us to take some medications with ourselves for the first visit, and come back to the clinic for more specific drugs that we need after we have taken a full history and done a complete physical examination. We had no idea what specific knee problem the patient had and with the limited resources we have, we could only take some ibuprofen just in case the patient’s problem was related to pain.

We took our first pack of pills and rode a jeep through a bumpy unpaved path and reached a little straw hut. Outside the hut a middle-aged man lying on a hammock outside the hut greeted us with a beaming smile and signalled us to go in. The entrance was clouded by the smoke from the charcoal stove placed just at the entrance.
We went in and walked through the door clouded by grey sooty smoke from the charcoal stove in the open-plan kitchen by the entrance. As we regained our vision we saw an old man lying on his wooden bed, accompanied by his wife who was sitting next to him.

“Can you please tell me your problem?” I asked in the most accurate Spanish accent I could speak.

“I feel some pain here,” he pointed at his abdomen.

‘What?” I thought, “Didn’t he have a knee problem?”

“Any pain in your knee?”

“No,” he looked at me, as confused as I was.

We then realized one of the assistants got the chief complaint of a few house calls mixed up.

I continued with my history taking and realized that this gentleman, Pedro Martinez, is a 73 years old retired non-smoker non-drinker with a chronic abdominal pain and chronic cough and chest pain with occasional bouts of shortness of breath. Pain from both sites has been present for more than 3 months and has been getting worse progressively. Mr Martinez wasn’t able to describe the nature of the pain but he did say that there has been no radiation to elsewhere in his body. There have also been no exacerbating and relieving factors. He has had difficulty and some pain in urination. Hesitancy was also present.

Apart from the abdominal pain he also had chest pain together with some shortness of breath especially apparent during exercise. He has also been wheezing and coughing with white sputum but no blood. He did not however have fever.

Mr Martinez never had any significant past medical illnesses nor was he aware of any other chronic medical or surgical problems since he had never had a body check. He did not even know whether or not he was hypertensive or diabetic. He claimed that he has been quite healthy throughout his life and never required any hospitalizations or surgeries.

None of Mr Martinez’s first degree relatives had the same problem as he does, and he lives with his wife, his 2 sons and a few grandchildren in this straw hut. He has become quite dependant on his wife due to the pain, however Mr Martinez can still take short walks around the neighbourhood with help.

I performed a full physical examination on him and palpated a grossly distended bladder with suprapubic tenderness. Digital rectal examination revealed a grossly enlarged and stone-hard prostate. Upon auscultation of his respiratory system, expiratory wheezing was heard. The rest of the examination of other systems was unremarkable. We then took his blood pressure and blood glucose. They were impressive numbers of 110/90 and 4.8 respectively.

Our diagnosis was a chronically enlarged prostate which blocked the urethra causing chronic retention of urine, resulting in the distended bladder and abdominal pain. This also precipitated to urinary tract infection causing more abdominal pain. The enlarged prostate was likely benign prostate hyperplasia which we think is highly unlikely to kill him, and that he will most likely by dying with it rather than from it.

The wheezing and occasional bouts of shortness of breath were caused by chronic obstructive pulmonary disease due to the chronic exposure of the smoke from the kitchen which was very poorly ventilated and located right next to the bed.

Mr Martinez then admitted that he has already went to see a doctor elsewhere before for his abdominal pain and his wife showed us some medicine he was prescribed, which they claimed did not really work and so they wanted to seek more advice from different doctors, hence the house-call.

Dr Keith smelled the pack of pills and suggested that it might be a sulphur-containing drug such as Cephalexin, a commonly used first generation cephalosporin commonly used in that locality. He suspected that it was used to treat his urinary tract infection which apparently failed and he recommended Mr Martinez to change to another type of anti- biotic, ciprofloxacin, which will work for the spectrum of bacteria possible for causing his urinary tract infection.

Apart from the antibiotic, we also prescribed salbutamol which was for symptomatic relief of his wheezing and shortness of breath; Terazosin, an alpha-blocker, for treating his benign prostatic hyperplasia, since surgery is not feasible for a man his age; and some Ibuprofen, an non-steroidal anti-inflammatory drug for symptomatic treatment of pain. We told him that we had to go get all those drugs from our inventory which was 10 minutes drive away, and that we would be back within an hour.

An hour later we returned with all the drugs as promised and also brought along urine multistix. The test indeed confirmed the diagnosis of UTI. So we did not have to go back to our inventory for other drugs!

As followup would be difficult for Mr Martinez, we had to make sure he knows very well how to use the meter dose inhaler before he leave his home. So we stayed around for a while to make sure he became familiar with every single step of the use of the inhaler. He had weak hands and had difficulty pressing the MDI to release the puff of salbutamol, so he asked his wife for assistance. The whole straw hut was filled with laughter as this old couple took their inhaler crash course.

When we were sure that the Martinez couple knew exactly how the MDI worked and that they have jotted down when to take the drugs, we bid them goodbye and returned to our village clinic.

Mrs Martinez assisting Pedro with the Salbutamol inhaler.

Pedro Martinez’s home



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